substance use disorders

Question 1

Trajectories

Answer 1

Transition from use to dependence

Alcohol: 15-23%, onset before age 30, 1:20 seek treatment
Nicotine: 68-32%, 5.1 % success rate per quit attempt
Cannabis: 9% within 10 years of initiation
Cocaine: 17-21% (for crack and iv use theres a higher risk)
Opioids: pill misuse 7.5%, heroin 23-30%, most persistent, often lifelong, periodic remissions common

Question 2

Risk factor models

Biological

Answer 2

Host, environment, agent vs
Bio-psycho-social-spiritual

Risk factors (biological- host perspective): pre-natal exposure, family history, early onset use, response to use (pharmacokinetics, receptor density, sensitivity, risk alleles), regular use, progression to harder and more drugs, medical conditions, psychiatric illnesses/disorder

Question 3

heritability

Answer 3

twin, family, adoption studies

Cocaine with the highest heritability of .65 to .79

Most substances around .4-.6

For nicotine: heritability for age of onset, amount smoked, persistence and cessation

phenotypic traits of children of fathers with alcohol addiction

B-endorphin response in relatives

Question 4

Genetics

Answer 4

twin studies, linkage studies, GWAS, exome sequencing identify risk genes

Like HTN, DM and autism, polygenic risk factor model

Initially: looking for biological suspects: alcohol metabolizing enzymes, Mu opioid receptor polymorphism

GWAS: SNPs related to K+ signaling involved in subsance use d/o

Question 5

Risks

Answer 5

Brain development, reward and risk is done by 13 but by 25 is when prefrontal cortex is done

Question 6

Psychological and spiritual risk factors

Answer 6

Psych: Maturity (Stress tolerance), risk taking proneness, novelty seeking, rebelliousness, impulsivity, lack of emotional control, impressionability exposure to adevertisement, favorable attitude towars substance use, risk preception, psychological mindedness, interpersonal relatedness, LGBTQI

spiritual- self image/ self worth, goals for the future, accountability, religiousity

Question 7

Risku drugs

Answer 7

Risky drugs: arrives at the reward center quickly (oral vs smoking)
Binds receptors tightly, activates receptor fully, activates the reward center strongly (cannabis vs heroin), leaves the brain quickly (fentanyl vs methadone)

Question 8

Risky drug and risky environment

Answer 8

repeated exposure, ease of access, legal landscape, mediating relationships: drug and alcohol misuse increase risk of getting opioids prescribed

Prior drug and alcohol misuse increase risk for opioid misuse/ additction

Question 9

social risk factors

Answer 9

Individual: trauma: ACE (Adverse childhood event)> 4: 10 x more likely ivdu >6:46, post natal stress- think epigenetics

Parental warmth, attitude towards substances and monitoring

Educational attainment, job, socioeconomic status

Percieved availability of drugs and alcohol

Peers (important for initiationonly no significant other, person with addiction living with pts

Neighborhood
Transitions- mobility- friends

GENETicssSSS

Question 10

Substance misuse

Answer 10

Substance misuse- purpose not consistent with legal or medical guidelines

Perscription drug misuse: use of perscription drugs in any way that a doctor did not direct, includes use without a prescription use in in greater amounts, more often or longer than told to take them or use in any other way a doctor did not direct to use them

Hazardous use: increases risk of harmful consequences
Harmful use: causing damage to health (physical/mental)

Question 11

Tolerance

Answer 11

Decrease in response to a drug as a result of repeated treatment with that drug

Pharmacokinetic- decreased quantitiy reaches site the drug affects

pharmacodynamic: reduced cellular response to repeated use

Behavioral either pharmacodynamics or drug independent learning (context dependent)

cross tolerance: between drugs of similar function or effect

Question 12

substance use disorder DSM

Answer 12

A problematic pattern of substance use leading to clinically significant impairment or distress, as manifested by at least 2 of the following, occurring within a 12 month period

11 criteria into 4 categories: Impaired control, social impairment, risky uuse, pharmacological criteria

Question 13

Impaired control

Answer 13

uses substance longer or in larger amounts than originally intended

Unseccessful attempts/desire to reduce use

Great deal of time spent getting substance or obsessing over substance
Craving for substance

Question 14

Social impairment

Answer 14

Failure to fulfill major role obligations at work, school or home
Continued use despite recurrent social or interpersonal problems
Abandonment/reduction of social or recreational activities

Question 15

Risky use

Answer 15

recurrent use in situations that are physically hazardous

Continued use despite knowledge of physical or psychological problems that are caused or exsacerbated by the substance

Question 16

Pharmacological criteria

Answer 16

Tolerance and withdrawal

Symptoms of tolerance or withdrawal occuring solely during appropriate medical treatment with perscribed meds are NOT counted (opioids for pain control)

Question 17

Addiction

Answer 17

Chronic, relapsing brain disease that is charcterized by compulsive drug seeking and use despite harmful consequences

Primary, chronic and relapsing brain disease characterized by an individual patholologically pursuing reward and or relief by substance use and other behaviors
Progressive illness that can lead to disability and death without treatment

Question 18

Dual diagnosis and comorbidity

Answer 18

Antisocial personality and bipolar, (adhd is less)

50-60
schizophrenia

Question 19

Neurobiology of addiction

Answer 19

several theories, no conclusinve answer, all models have short coming

Question 20

stages of the addiction cycle

Answer 20

Binge intoxication–> tolerance, withdrawal, comprised social, occipational or recreational activites–>

Withdrawal negative Affect–> preoccupation with obtaining, persistent physical/ psychological problems–>

Preoccupation anticipation–> persistent desire, larger amounts taken than expected–> Binge

Question 21

Disre formation

Answer 21

Wanting Dopamine

Question 22

Addiction represents a dysregulation of incentive salience, reward (deficit), stress (surfeit) and executive function systems

Answer 22

Non addicted brain– saliency –> control stops–> drive

Addicted brain

Negative reinforcement

Question 23

re- entering actie disease- relapse

Answer 23

drug induced, Cue induced- external and internal, stress induced

Progressive illness- even with longer sobriety, people often start out worse into the relapse than at the end of the last sobriety stretch

Question 24

Assessment of substance use

Answer 24

Therapeutic assessment can help foster insight and motivation

Open ended questions, non judgmental

Drug use- Ask the same question twice, be concrete and specific (how many drinks does it take to get drunk), ask if they understand the question, ask if they understand the question, elicit pattern of use increase, decrease over time attemts to d/c
Context consequences and attidute

integrate drug use hisotory with life event history, builds understanding of triggers, level of insight insight, help seeking and accepting , context, consequences, attitude

integrate drug use history with life event history, builds understanding of triggers, level of insight, help seeking and accepting , other risk and supportive factors

Question 25

treatment planning

Answer 25

no single treatment appropriate for all

About 11% of people who need treatment get it
However only 5% of the people defined as needing treatment think they need it

treatment planning according to the bio psycho social spiritual model

Good idea to refer to the aSAM dimension

Question 26

treatment principles

Answer 26

Medication assisted treatment recovery: agonist therapy, partial agonist therapy, antagonist therapy

Psycho-social-spiritual modalitiesL individual therapy, group therapy, family therapy, peer support, social support, community support

Question 27

Medication assisted recovery opioid use disorder

Answer 27

reduces- relapses rates, overdose deaths, hepatitis C, HIV infection andtransmission, drug related crime

Improves- brain health, work retention, physical health, mental health , preganaccy outcomes

Question 28

Cognitive behavioral therapies

Answer 28

motivational enhancement therapy- short term, structured applied motivational interviewing and structured assessment and feedback

twelve step facilitation therapy- manual guided with emphasis on 12 step providing tools for recovery

individual drug counseling

manualized drug counseliing- stresses abstinence to achieve and maintain abstinence, 12 step participation

cognitive behavioral relapse prevention , recognizing triggers for drug use and rehearsing coping skills